CT BHP ProviderConnect Outpatient Requests
Contents
1. INITIAL TEMP000700058 CBHP000454 004175776 SELECT v Level of Service Type of Service Level of Care Type of Care Authorized User OUTPATIENT COMMUNITY BASED Mental Health Outpatient Outpatient Evaluation C A R E S All Selos marked with an asterisk are required Note Disable pop up blocker functionality to view al appropriate sinks Type of Services Type of Service MENTAL HEALTH Diagnosis Please indicate primary diagnosis Axis I Axis IT Diagnosis Code 1 Description Diagnosis Code 1 Description Ad ee NE o 799 9 DIAGNOSIS DEFERRED AXIS 1 OR 2 15 IT Product Support Reston VA Completing Requests for Outpatient Evaluations continued Key Step 4 Once the Submit button is clicked from the final clinical screen the submission Submit Request screens will display The specific screens that display vary depending on if the and Confirm request is approved or pended Submission For the Outpatient Evaluations the request will most likely auto approve meaning that the requested registration will be an approved authorization 1 For approved request the status would indicate Approved at the top of the screen Member Marne Member ID Member DOB Subscriber Mame MOONET WOODSIN TEMPO00070005 01 15 1995 MOONEY WOODSIN Authorization Client Authorization Type of Request OF1710 1 4 U0219532 INITIAL Date of Admission Start of Services From To Submission Date 08 17 2010 08 172. O Unknown indicate that only one data item can be selected for that field Click inside of the circle to select the value Save Request as EHD A Save Request as Draft button is available on the Draft Request for Services screens which will save the record when clicked As a saved record it is only available within ProviderConnect and is not available to access in CareConnect A Submit button is available on some screens which husnes will submit the record when clicked Member s Guardian Any open text box indicates that free form text can be entered into the box 4 IT Product Support Reston VA Accessing ProviderConnect Overview The ProviderConnect web application can be found on the COBH website 1 Go to www COBH com 2 Click on For Providers VALUEOPTIONS About Services Reports CONNECTICUT Contact News amp Events For Members gt Governor Rell Phenomenal 3 Click on Log In Provider Online Services Welcome to the Connecticut Behavioral Health Partnership CT BHP Online Services ProviderConnect Login or register with ProviderCoannect an online tool that allows you to check member eligibility enter authorization requests for CT BHP registered services view authorization letters and more Providerlonnect is easy to use secure and available 24 7 4 New Users without an ID proceed to Page 6 otherwise 5 Enter User ID and Password Please Log In Required
3. delaying authorization and billing Confirm submission of request The Results screen will display once the Accept button is clicked on the previous screen For approved requests the status would indicate Approved at the top of the screen For pended requests Psychological testing Ambulatory Detox concurrent reviews the status would indicate Pended at the top of the screen with a message indicating that the request requires further review The Results screen provides a summary of information about the request Print the request Click the Print Authorization Result button to print a copy of the Results page Click the Print Authorization Request button to print a copy of all the screens fields completed for the request including the clinical screens and the Results page Download the request Click the Download Authorization Request button to save a copy of the request either in pdf format or xml Exit the Request for Authorization function Click the Return to Provider Home to exit the Request for Authorization function 27 IT Product Support Reston VA Completing Concurrent Requests for Registered Services Overview Creating Concurrent request in ProviderConnect follows the same process as completing a new request but with some variations within each step This is because ProviderConnect will automatically determine when a request is initial or concurrent by checking for existing authorizations on file fo
4. selected in order to complete the request Conditionally required fields will not have asterisks Back Button A Back button is available on most ProviderConnect screens to help navigate to previous screens The Back button on the ProviderConnect screens should only be used when navigating to the previous screen Do not use the back button on your Internet browser Calendar Icon Hil For date fields a pop up calendar can be accessed by clicking the calendar icon When the calendar opens click the date desired and the date field will automatically update with the selected date Cancel Button A Cancel button is available within some screens to hassel allow a user to exit from the function Checkboxes re Any data items with checkboxes next to them indicate that more than one data item can be selected for that Bi cardiovascular Problem field Click inside of the box to select the value Expand Collapse Any title with an arrow gt to the left of the title Narrative Entry indicates that it is a section that can be expanded to display fields or information Click on the title to expand or collapse the section Hyperlinked Any underlined codes that are input options for a field Codes 01 3 will populate the field when clicked Hyperlinked Diagnosis Code 1 Any underlined field title will open screens help text a Field Titles T list of codes etc when clicked Radio buttons Any data items with radio buttons next to them O ves No
5. 2010 08 22 2010 08 17 2010 Level of Service Type of Service Level of Care Type of Care OUTPATIENT COMMUNITY BASED MENTAL HEALTH OUTPATIENT OUTPATIENT EVALUATION C A R E 5 Reason Code A70 Provider Mame amp Address Provider ID Provider Alternate ID NPI for Authorization THE HARTFORD DISPENSARY CBHPO00454 004175776 N A 335 BROAD ST 3RD FLOOR MANCHESTER CT 06040 16 IT Product Support Reston VA Completing Initial Requests for Registered Services Key Step 1 The first key step is to initiate the request for authorization function which starts from Initiate a Request the ProviderConnect Homepage The function can also be initiated when the for Authorization Member record is located first and then the Enter an Auth Request button is clicked Below are the key actions for completing this step Any field with an asterisk indicates that the field is required 1 Click enter an Authorization Request link from either the left navigational or Home page of ProviderConnect gaging Home TT Welcome Thank you for using ValueOptions ProviderConnect Authorization Listing Request YOUR MESSAGE CENTER view Clinical Drafts Review Referrals Your Recent Inquiries box is empty Enter Bed Tracking Information WHAT DO YOU WANT TO DO TODAY My Online Profile Eligibility and Benefits Review Peferrals e Find a Specific Member a Review Referrals Enter or Review Authorization Requests View My Recent A
6. AND SUBSTANCE ABUSE CONDITIONS The Special Population screen will display next 24 IT Product Support Reston VA Completing Initial Requests for Registered Services continued Key Step 7 The Special Populations screen captures information specific to the following types Complete the of members Clinical Screens Members Age 0 18 ORF2 Special Ambulatory Detox Populations Seea If the member is not any of the types listed then this screen can be skipped If the member is one or more of those types the sections that must be completed will be automatically expanded to display the fields that must be completed Below are the key actions for completing this step Any field with an asterisk indicates that the field is required Action Complete the Member s Age 0 18 section if expanded SED SERIOUSLY SEVERELY EMOTIONALLY DISTURBED CO OCCURING DISORDER LIVING SITUATION WITHIN THE PAST 12 MOS HAS THE CHILD YOUTH BEEN ARRESTED WITHIN THE PAST 12 MOS HAS THE CHILD YOUTH BEEN SUSPENDED EXPELLED Complete the Ambulatory Detox section if expanded At a minimum the following fields are required for completion for initial requests FROM WHAT SUBSTANCE IS THE MEMBER IN NEED OF DETOXIFICATION HAS THE MEMBER HAD PREVIOUS DETOX IN ANY SETTING IN THE PAST YEAR o If yes number of detoxes in the past year WHAT IS THE IDENTIFIED DISCHARGE PLAN Click the Next button The Treatment Plan scree
7. Based and Psychological Testing services d Substance Abuse should be chosen for SA Outpatient Ambulatory Detoxification Services Select the Level of Care Outpatient Select the Type of Care Requested level of care amp provider type of the service i e Outpatient Comm Mntl Hlth Ctr Home Based Services MDFT Individual Clinic NOTE The Type of Service and the Type of Care MUST match the selections made on the initial registration for the request to be considered a concurrent review Attach a document COBH registered services do not require attached documents users can proceed to step 7 Click the Next Button A warning message will pop up to confirm if you want to proceed without attaching a document Click the OK button to proceed staging Requested Services Header AN elde marked with an asterisk are required Note Disable pop up blocker functionality to view al appropriate Jinks Level of Service OUTPATIENT COMMUNITY BASED Provider Provider Alternate ID Tax ID Provider ID Provider Last Name Vendor ID 060646665 CBHP000454 HARTFORD DISPENSARY VCB006009 004175776 Member ID Member Last Name First Name Date of Birth MMDDYYYY TEMP000700058 WOODSIN MOONEY 01151995 Attach a Document Complete the form below to attach a document with bis Request The following fields are only required if pou are uploading a document Document Type Does this Document contain clinical information abo
8. Click Specific Member Search from the navigational bar or Find a Specific Member on the Home page Staging Home eectic Member Search Welcome THE HARTFORD DISPENSARY Thank you for using Valu Authorization Listing Enter an Authorization Request YOUR MESSAGE CENTER view Clinical Drafts Recent Inquires Responded to by valueQptions Review Referrals Enter Bed Tracking DATE RECEIVED SUBIECT Information LY ie ites n REFERRAL My Online Profile WHAT DO YOU WANT TO D TODAY Eligibility and Benefits m Find a Specific Member 2 Enter values for the Member ID and Date of Birth a Note The As of Date MBR Eligibility Date will auto populate with today s date To search a previous eligibility date users can enter a previous date Eligibility amp Benefits Search Required fields are denoted by an asterisk I adjacent to the label verify a patient s eligibility and benefits information by entering search criteria E member ID te spaces or dashes Last Marne First Marne Date of Birth eweye As of Date 08162010 roo rrr 8 IT Product Support Reston VA ProviderConnect Basics continued Review Members record details 3 Demographics Displays basic member information i e address phone etc 4 Enrollment History Displays active and expired enrollment records for member 5 COB Display information on other insurance policies 6 Additional Information Displays claims mailing address f
9. OUTPATIENT TREATMENT WITHIN YOUR AGENCY PRACTICE o NOTE TO ECC PROVIDERS This field has been updated This field now is inquiring if this registration is for a client ALREADY IN outpatient treatment with your facility If aclient has recently become HUSKY eligible but has already been previously receiving services through your agency practice ECC users should select YES thus removing this registration from your access standards If the client is HUSKY eligible and is a new admission to your facility ECC users should select NO IS MEMBER STEPPING DOWN TO OUTPATIENT FROM A HIGHER LEVEL OF CARE WITHIN YOUR AGENCY PRAGTICE o NOTE TO ECC PROVIDERS Users should select YES if a member is stepping down from a higher level of care within your agency practice thus removing this registration from your access standards Select the REFERRAL SOURGE sn TI Enter the date of the FIRST PHONE OR WALK IN CONTACT WITH MEMBER OR PARENT GUARDIAN and select the method for the FIRST CONTACT WAS Select the REFERRAL TYPE Ifthe Referral Type is Routine or Urgent then complete the conditionally required fields for Routine or Urgent referrals o DATE OF FIRST APPOINTMENT OFFERED TO MEMBER o DATE OF FIRST APPOINTMENT ACCEPTED BY MEMBER o DATE OF FIRST FACE TO FACE CLINICAL EVALUATION If the Referral Type is Emergent then complete the conditionally required fields for Emergent referrals o DATE AND TIME PRESENTED AT THE CLINIC Ti
10. Requested Start Date is the date for the authorization to begin in order to cover requested services 11 Select the Level of Service Outpatient Community Based When the level of service is selected the screen will update with the required fields specific to the level of service 12 Select the Type of Service a Mental Health should be chosen for MH Outpatient Home Based and Psychological Testing services b Substance Abuse should be chosen for SA Outpatient and Ambulatory Detoxification Services 13 Select the Level of Care Outpatient 14 Select the Type of Care Requested level of care amp provider type of the service i e Outpatient Comm Mntl Hith Ctr Outpatient Office Psych Testing Office Home Based Services MDFT Individual Clinic 15 Attach a document COBH registered services do not require attached documents users can proceed to step 7 16 Click the Next Button A warning message will pop up to confirm if you want to proceed without attaching a document Click the OK button to proceed Staging Requested Services Header All Feld marked with an asterisk are required Note Disable pop up blocker functionality to view al appropriate links Level of Service OUTPATIENT COMMUNITY BASED V Provider Provider Last Name Vendor ID Provider Alternate ID 060646665 HARTFORD DISPENSARY CB006009 004175776 Member L Date of Birth MMDDYYYY TEMP000700058 WOODSIN 01151995 Attach
11. a Document Complete be form below to attach a document with this Request The following fields are only required if pou are uploading a document Document Type Does this Document contain clinical information about the Member Yes No O bi e SELECT UploadFile Glink to attach a document Attached Document Microsoft Internet Explorer 2 WARNING You have not attached document to this Request Please click CANCEL to return to the screen to attach a document or click OK to proceed with your request 4 without attaching document 20 IT Product Support Reston VA Completing Initial Requests for Registered Services continued Key Step 3 For Outpatient Services requests the clinical screens for the Outpatient Request Complete the Form 2 ORF2 workflow will display This workflow consists of five 6 clinical Clinical Screens screens The amount of information collected within each screen varies and not all ORF2 fields are required 1 Type of Services Diagnosis Current Risks Special Population Treatment Plan Psychotropic Medications oo ON Below is information for completing each screen Key Step 3 The screens will display in the order listed above when the Next button is clicked Complete the within each screen Clinical Screens Requests must be completed in order All required fields must be completed to ORF2 Tips for move to the next screen k a ee Previous screens can be accesse
12. fields are denoted by an asterisk I adjacent to the label Please log in by entering your User ID and password below User ID If you do not remember your User ID please contact our e Support Help Line Password Forget Your Password Log In The information and resources provided through the ValueOptions site are provided for informationa ValueOptions site Providers are solely responsible for determining the appropriateness and mani 6 Click Log lIn 7 Proceed to Page 8 5 IT Product Support Reston VA ProviderConnect Basics New Users IMPORTANT NOTE The ProviderConnect Register process below allows users the ability to gain access to the ProviderConnect application and create their own password and security question The system allows only 1 user per facility or group or individual practice to register If additional users or new staff members need access to ProviderConnect users can contact the ValueOptions e Support Help Line to have a user ID Password created and to have that id password be associated with the facility practice e Support Help Line 1 888 247 9311 Provider New users must register to access New User Registration ProviderConnect Please register for access Process for NEW Click on Register bottom of Log in page USERS The Provider Online Services Registration screen will display Fill out the fields Note The fields with a red asterisk are required 1 2 3 o
13. initial entry request screen 3 Update the clinical screens ORF2 4 Submit Request and confirm submission __ KeyStep1 The first key step is to initiate the request for authorization function which starts from Initiate a Request the ProviderConnect Homepage The function can also be initiated when the for Authorization Member record is located first and then the Enter an Auth Request button is clicked Follow Step 1 on Pages 17 19 28 IT Product Support Reston VA Completing Concurrent Requests for Registered Services continued Key Step 2 The second key step is to complete the initial entry screen of the request where the Complete Initial requested start date of the service is entered and the specific level of care and Entry Request service is selected This screen displays for all types of requests However the Screen information entered determines which clinical screens will display and which authorization parameters will be applied to the request Any field with an asterisk indicates that the field is required 1 Enter the Requested Start Date The Requested Start Date is the date for the authorization to begin in order to cover requested services Select the Level of Service Outpatient Community Based When the level of service is selected the screen will update with the required fields specific to the level of service Select the Type of Service c Mental Health should be chosen for MH Outpatient Home
14. A Completing Initial Requests for Registered Services continued 7 Locate and select the Service Address Vendor 8 Click the radio button next to the Service Address to select record The record that is selected will be attached to the request and authorization that will be created 9 Click the Next button to continue The Requested Service Header will display HARTFORD DISKENSARTY GBHHUUDSJO9 W Select Service Address Provider vendor Provider ID Last Name vendor ID Ve First Mame Ye Mam Service Address Paid To Yendor ID Pa CEHP DD454 HARTFORD DISPENSARY WCBOO0S 76 THE 060646665 345 MAIN ST HARTFORD CT 06106 1824 004175776 CEHPO00454 HARTFORD DISPENSARY WOBOO4G9 THE 060646665 12 WESTON ST 16 HARTFORD CT 06120 1504 00417577 CEHPO0O454 HARTFORD DISPENSARY WOBOOS231 THE 19 IT Product Support Reston VA Completing Initial Requests for Registered Services continued Key Step2 The second key step is to complete the initial entry screen of the request where the Complete Initial requested start date of the service is entered and the specific level of care and Entry Request service is selected This screen displays for all types of requests However the Screen information entered determines which clinical screens will display and which authorization parameters will be applied to the request Any field with an asterisk indicates that the field is required 10 Enter the Requested Start Date The
15. Button Disclaimer Please note that ValueOptions recognizes only fully completed and submitted requests as formal requests for authorization recognize or retain data for partially completed requests Upon full completion of the Enter an Authorization Request pri notification that your request has been received by ValueOptions 3 Search for Member Record Member s Medicaid ID and Date of Birth are required Required fields are denoted by an asterisk J adjacent to the label Verify a patient s eligibility and benefits information by entering search criteria below Member ID temp000 700053 Vo spaces or dashes Last Marne First Marne Date of Birth 01151995 MMDDYYYY As of Date 08172010 MMDDYTYY 4 Click the Next button on the Member record to continue Men ber Member ID T E hi EF l l l D Ii Ii GE Alternate ID Member Hame nar O O O S Ii HOONES Cate of Birth On 15 190905 So dress S00 ENTERPRISE DOF HAATPFORG He EF pb Alternate Address Marital Status Home Phone wy ork Phone Felation hip Sender 5 The Select Service screen will display 12 IT Product Support Reston VA Completing Requests for Outpatient Evaluations continued 6 Locate and select the Service Address Vendor 7 Click the radio button next to the Service Address to select record The record that is selected will be attached to the request and authorization that will be created 8 Click the Next but
16. CHARTER GAK Ar Behavioral Health ProviderConnect Registered Services User Manual N VALUEOPTIONS CONNECTICUT 3 IT Product Support Reston VA This page was intentionally left blank Table of Contents Tal i gele 10101110 9 DDE 3 eies SING FOV IG SOIC CE RE EEE 5 ProviderLonned BASICS s ci n nc lar aonina nik d xak n l nahiy bk nek a dl ne dayk kanik ae k parkan k paa hl bna dn k aa kw R 6 FU 10 Completing Requests for Outpatient Evaluations rrarennnrrnanernnnrnnnrnranennnnnrnnrnnnnrnnrrnnnnennn 11 Completing Initial Requests for Registered Services l i kk 17 Completing Concurrent Requests for Registered Serv C S LA Ah ll EE 28 Completing Requests for Psychological T Sting cccccseccsseeteeeceeeeeeeeteueeseeteneeseeeeaes 31 2 IT Product Support Reston VA Introduction Introduction The ProviderConnect application provides a variety of self service functions to help providers access and view information about members and authorizations For COBH providers additional functionality is available including Obtaining authorizations for Outpatient evaluations Obtaining authorizations for COBH Registered Services Outpatient Ambulatory Detoxification and Home Based services Submitting requests for Psychological Testing services Submitting Inpatient discharge information What is Covered This module covers general functions within ProviderConne
17. EL to return to the screen to attach document or click OK to proceed with your request 2 without attaching document 32 IT Product Support Reston VA Completing Requests for Psychological Testing continued IMPORTANT Once the clinical screens NOTE Saving in ProviderConnect have Me td Requests as been accessed providers Drafts have the ability to save a TONS request as a draft in the event that they cannot complete it at the ime the lt 4 C9Q9Q44 request was started Users can click Save Request as Draft on the top right of the screen Saved drafts can be viewed and opened by providers from the View Clinical Drafts screen accessible from the ProviderConnect homepage See pg 11 Key Step 3 For Psychological Testing requests there will be only 1 screen Outpatient Psych Complete the Testing to complete Fields with asterisks are required Clinical Screen See EE RESULTS PAGE i af 2 BE Requested Services Header Below are the key actions for completing this step Any field with an asterisk indicates that the field is required Action Enter the Contact Name of Clinician Psychologist performing the testing Enter the Phone Number of Clinician Psychologist performing the testing Indicate Yes or No for ARE YOU INDEPENDENTLY LICENSED Complete WHAT ARE THE REFERRAL QUESTIONS AND WHY IS TESTING BEING REQUESTED AT THIS TIME Indicate HAS PATIENT BEEN EVALUATED BY A PSYCHIATRIST an
18. TMENT PLAN EXIST ANTICIPATED TARGET DATE FOR ACHIEVEMENT OR CURRENT TREATMENT PLAN GOALS Click Next button The Psychotropic Medications screen will display next The medication fields are not required but should be completed if applicable IT Product Support Reston VA Completing Initial Requests for Registered Services continued Key Step 9 Once the Next button is clicked from the final clinical screen the submission screens Submit Request will display The specific screens that display vary depending on if the request is and Confirm approved or pended Submission For the Outpatient Services new requests will most likely auto approve meaning that the requested authorization will be an approved authorization For auto approved requests two screens display the Accept Reject screen and the Confirmation screen If the request is pended for some reason only one screen will display the Confirmation screen Below is information for submitting request for both auto approved and pended requests Auto Approved Requests Action COBH providers should always click the Accept Button on the confirm submission screen o When the Accept button is clicked the request will auto approve and an authorization will be created with the indicated number of visits approved COBH users should not click the Reject button If a user clicks Reject the request will NOT be approved Rather it will be pended to the COBH clinical staff
19. cs New Users continued Provider A password must be created on the same Provider Online Services Registration Registration screen To create a password Process 1 Enter a password in the Select a Password field Passwords e Must be between 8 10 characters in length May contain numbers and uppercase letters Cannot contain lowercase letters Cannot contain spaces e Are case sensitive Enter the same password in the Confirm New Password field Create a question in the Password Reminder field Enter the answer to the question in the Password Reminder Answer field Click Submit oe Sek he Passwords must be at least eight 8 characters long but no longer than ten 10 Password is case sensitive Select a Password Confirnn New Password Create a Security Question Answer to Security Question Please check the provider services Inquiry Functions Claims Authorizations Patent Eligibility and Benefits searches Will be available automa For assistance with any technical problems such as connecting to or accessing the Support Specialist at e SupportServicesmyvalueoptions cam 7 IT Product Support Reston VA ProviderConnect Basics continued Searching for One function that is used often to for various ProviderConnect functions is searching and Viewing and viewing member records Member Records Below are the key actions for completing this step Any field with an asterisk indicates that the field is required 1
20. ct as well as requests for in this Module Outpatient evaluations and services which includes the following key functions Registering Outpatient Evaluations This process focuses on completing a registration authorization for an Outpatient evaluation Registering Initial Outpatient Services This process focuses on completing a registration authorization for an initial outpatient service Registering Concurrent Outpatient Services This process focuses on completing a registration authorization request for a concurrent Outpatient service Training As a result of this training module you will be able to Objectives u Log in to ProviderConnect Search for and view Member records Complete a request for an Outpatient Evaluation authorization Complete a request for an initial Outpatient service authorization Complete a request for a concurrent Outpatient service authorization 3 IT Product Support Reston VA Introduction continued Navigation Throughout the ProviderConnect screens navigation features are available to make Features it easier to move through the fields and screens Below are a few basic features available Feature What it Looks Like Description Breadcrumbs T Tabs with titles of each request screen will display on all of the request screens to show progress through the process Mee Any field with an asterisk next to it indicates that the field is required and a data item must be entered or
21. d IF YES WHEN if applicable Enter the DIAGNOSIS CODE 1 for Axis I or Axis Il DIAGNOSIS CODE 1 is required for Axis If no value or a partial value is entered in the Diagnosis Code or Description fields and the field title is clicked a list of codes will pop up displaying the full list of values and descriptions or those that match the partial value Click the code to populate the CODE and DESCRIPTION fields DIAGNOSIS 2 and DIAGNOSIS 3 are optional 33 IT Product Support Reston VA Completing Requests for Psychological Testing continued Step Action Check all applicable options for AXIS IV if needed Enter the CURRENT GAF SCORE for Axis V if needed Indicate Is patient currently in treatment If yes complete the If Yes specify modality e g individual group family Indicate Are there clinical explanations other than psychological ones that could explain current behaviors symptoms i e thyroid dysfunction closed head injury medications poisoning etc Click the Tests planned and time required hyperlink Test s planned and time required A pop up window and a listing of psychological neurological tests A B will display Search window will have the name of the test test type age range for testing and the standard time that the test should take to complete Users will select the planned tests by clicking the check boxes on the left hand side Users can also navigate through the listing of test
22. d by clicking the Back button However you Screens must click the Next button to proceed forward u Within any clinical screen the request can be saved as a draft by clicking the Save Request as Draft button within the screen header saging YTYPE OF SERVICES gt CURRENT SPECIAL POPULATION gt TREATMENT PSYCHOTROPIC REQUESTED RESULTS RISKS PLAN MEDICATIONS SERYICES IMPORTANT Once the clinical Requests as ProviderConnect have Drafts been accessed i providers have the TONS ability to save a request as a draft in the event that they cannot complete it at the time MN the request was started Users can click Save Request as Draft on the top right of the screen Saved drafts can be viewed and opened by providers from the View Clinical Drafts screen accessible from the ProviderConnect homepage See pg 11 21 IT Product Support Reston VA Completing Initial Requests for Registered Services continued Key Step 4 The Type of Services screen is the first screen that will display after the Initial Entry Complete the screen Much of the information is required for completion on this screen Clinical Screens ORF2 Type of Below are the key actions for completing this step Any field with an asterisk Services Screen indicates that the field is required Step Action 1 Enter the MEMBER S GUARDIAN if needed S O Complete the required questions IS THIS ANEW REGISTRATION FOR A CLIENT ALREADY IN
23. ected to be updated for a concurrent request will auto populate from the initial or last request The pre populated fields can be overwritten with new data Action Type of Services Screen Displays Click the Next button The Diagnosis screen will display next Update Diagnosis if applicable Click the Next button The Current Risks screen will display next The Current Risks fields will need to be completed to move onto the next screen Click the Next button The Special Population screen will display next Update Fields if applicable Click the Next button The Treatment Plan screen will display next The Treatment Plan fields and the Re Registration Only fields will need to be completed to move onto the next screen Indicate Degree of Progress from previous registration Treatment Modalities to be used w this request Family Individual Group Medication Management and Frequency Click the Next button The Psychotropic Medications screen will display next Update Fields if applicable Click the Next button Submit Request 30 IT Product Support Reston VA Completing Requests for Psychological Testing Overview ProviderConnect provides the ability for providers to complete requests for Psychological Testing using an easy to follow workflow Psychological Testing requests will pend to the COBH for review by our Medical Directors Key Steps The key steps for creating requests for Psycholo
24. for completion and submission for 30 days from the initial date the record was saved If the record is not submitted within the 30 days it is automatically expired Log Out View Clinical Drafts Please select the Provider ID below to vier and click the Search Drafts button to view Saved and Expired Clinical Requests or Saved and Expired Plans for a different provider Provider ID CBHPOO0454 Search Drafts Saved Clinical Request Drafts eee Saved request drafts will automatically expire 30 days after the Initial Saved Date Delete Request Drafts Nenk gt gt Initial Saved Date Member ID Member Manne Provider ID Level of Service Level of Care Type of Care Authorized User Requested Start Date A n 08 16 2010 TEMPO00700058 WOGCDSIN MOONEY CBHPOMDA4 Op Outpatient Family Support Teams FST Home 08 16 2010 View Open Nent gt gt When a record is saved as a draft it is NOT available for COBH clinical staff to review 10 IT Product Support Reston VA Completing Requests for Outpatient Evaluations Overview ProviderConnect provides the ability for providers to complete requests for Outpatient Evaluations using an easy to follow workflow For Outpatient Evaluations only the Axis I Diagnosis Code 1 is required for completion Most requests will auto approve unless the request does not pass the system validations Key Steps The key steps for creating requests for Outpatient Evaluation authorizations include Init
25. gical Testing authorizations include Initiate a Request for Authorization Complete the initial entry request screen Complete the clinical screens for Psychological Testing Submit Request and confirm submission go N e ol Details about each key step follow Key Step 1 The first key step is to initiate the request for authorization function which starts from Initiate a Request the ProviderConnect Homepage The function is initiated when the Enter an for Authorization Authorization Request button is clicked The key actions to these steps are covered on Pages 18 20 of this manual 31 IT Product Support Reston VA Completing Requests for Psychological Testing continued Key Step2 The second key step is to complete the initial entry screen of the request where the Complete Initial requested start date of the service is entered and the specific level of care and Entry Request service is selected This screen displays for all types of requests However the Screen information entered determines which clinical screens will display and which authorization parameters will be applied to the request Any field with an asterisk indicates that the field is required 17 Enter the Requested Start Date The Requested Start Date is the date for the authorization to begin in order to cover requested services 18 Select the Level of Service Outpatient Community Based When the level of service is selected the screen will update with
26. he request Any field with an asterisk indicates that the field is required 1 Enter the Requested Start Date The Requested Start Date is the date for the authorization to begin in order to cover requested services 2 Select the Level of Service Outpatient Community Based When the level of service is selected the screen will update with the required fields specific to the level of service 3 Select the Type of Service Mental Health 4 Select the Level of Care Outpatient 5 Select the Type of Care Outpatient Evaluation Outpatient Services Stagims Requested Services Header Al Selo marked with an asterisk are required Note Disable pop up bocker functionality to view al appropriate finks Level of Service Requested Start Date MMDDYYYY 08172010 OUTPATIENT COMMUNITY BASED v Level of Care Type of Care OUTPATIENT La OUTPATIENT EVALUATION C A R E S Provider Tax ID Provider ID Provider Last Name vendor ID Provide 060646665 CBHP000454 HARTFORD DISPENSARY vCB006009 00417 6 Attach a document COBH registered services do not require attached documents users can proceed to step 7 7 Click the Next Button A warning message will pop up to confirm if you want to proceed without attaching a document Click the OK button to proceed Cas Jr Microsoft Internet Explorer WARNING You have not attached document to this Request Please click CANCEL to return
27. ial Requests for Registered Services continued Key Step 6 The Current Risks screen captures a snapshot of the member s current mental Complete the status by allowing providers to complete ratings for the member s risk to self and risk Clinical Screens to others and thirteen 13 different impairments ORF2 Current HIKE Sereen Below are the key actions for completing this step Any field with an asterisk indicates that the field is required Click the radio button for the appropriate rating for Current Risks MEMBER S RISK TO SELF MEMBER S RISK TO OTHERS Click the radio button for the appropriate rating for Current Impairments MOOD DISTURBANCES DEPRESSION OR MANIA WEIGHT LOSS ASSOCIATED WITH AN EATING DISORDER ANXIETY MEDICAL PHYSICAL CONDITIONS PSYCHOSIS HALLUCINATIONS DELUSIONS SUBSTANCE ABUSE DEPENDENCE THINKING COGNITION MEMORY CONCENTRATION PROBLEMS JOB SCHOOL PERFORMANCE PROBLEMS IMPULSIVE RECKLESS AGGRESSIVE BEHAVIOR SOCIAL FUNCTIONING Complete additional required information when the rating is a 2 or 3 for the following fields A sub section will expand to display the fields that need to be completed WEIGHT LOSS ASSOCIATED WITH AN EATING DISORDER SUBSTANCE ABUSE DEPENDENCE LEGAL Complete additional required information when the LEGAL impairment rating is a 1 2 or 3 A sub section will expand to display the fields that need to be completed MENTAL HEALTH
28. iate a Request for Authorization Complete the initial entry request screen Complete the clinical screens Outpatient Treatment Request 1 ORF1 Submit Request and confirm submission od I Details about each key step follow Key Step 1 The first key step is to initiate the request for authorization function which starts from Initiate a Request the ProviderConnect Homepage The function can also be initiated when the for Authorization Member record is located first and then the Enter an Auth Request button is clicked Below are the key actions for completing this step Any field with an asterisk indicates that the field is required 1 Click enter an Authorization Request link from either the left navigational or Home page of ProviderConnect eqtaging Home Welcome Thank you for using ValueOptions ProviderConnect Specific Member Search Authorization Listing Request YOUR MESSAGE CENTER view Clinical Drafts Review Referrals Your Recent Inquiries box is empty Enter Bed Tracking Information WHAT DO YOU WANT TO DO TODAY My Online Profile Eligibility and Benefits Review Peferrals a Find a Specific Member a Review Referrals Enter or Review Authorization Requests View My Recent Authorization Letters Review an Authorization e View Clinical Drafts 11 IT Product Support Reston VA Completing Requests for Outpatient Evaluations continued 2 Review the Disclaimer and click the Next
29. me must be entered as military time i e 2 00pm 1400 and 2 am 0200 o DATE AND TIME OF CLINICAL EVALUATION Time must be entered as military time i e 2 00pm 1400 and 2 am 0200 Click the Next button The Diagnosis screen will display next 22 IT Product Support Reston VA Completing Initial Requests for Registered Services continued Key Step 5 The Diagnosis screen allows the capture of multiple diagnoses for Axis I Axis Il Axis Complete the and Axis IV as well as the Current GAF Score for Axis V However not all Axes Clinical Screens are required ORF2 Diagnosis Sereen Below are the key actions for completing this step Any field with an asterisk indicates that the field is required Enter the DIAGNOSIS CODE 1 for Axis I or Axis II DIAGNOSIS CODE 1 is required for Axis I If no value or a partial value is entered in the Diagnosis Code or Description fields and the field title is clicked a list of codes will pop up displaying the full list of values and descriptions or those that match the partial value Click the code to populate the CODE and DESCRIPTION fields DIAGNOSIS 2 and DIAGNOSIS 3 are optional Check all applicable options for AXIS IV if needed Enter the CURRENT GAF SCORE for Axis V if needed Click the Next button The Current Risks screen will display next Check all applicable options for Axis Ill if needed 23 IT Product Support Reston VA Completing Init
30. n will display next 25 IT Product Support Reston VA Completing Initial Requests for Registered Services continued Key Step 8 Complete the Clinical Screens ORF2 Treatment Plan 26 Screen The Treatment Plan screen captures information specific to the members plan for treatment while they are receiving services from the provider Note The Re registration section can be skipped for initial requests This section is only required for concurrent requests Below are the key actions for completing this step Any field with an asterisk indicates that the field is required Action Indicate Yes or No for IS PSYCHIATRIC MEDICATION EVALUATION OR MEDICATION MANAGEMENT VISIT INDICATED Indicate Yes or No for HAVE YOU PROVIDED INFORMATION REGARDING PEER SUPPORT OR SELF HELP OPTIONS Indicate Yes or No for DO FAMILY MEMBERS OR SIGNIFICANT OTHERS ACTIVELY PARTICIPATE IN THE MEMBER S TREATMENT AND RECOVERY If Yes is selected complete the follow up question IF YES ARE ANY OF THE FAMILY MEMBERS SIGNIFIGANT OTHERS RECEIVING THEIR OWN MH OR SA TREATMENT Select valid options to indicate the consent obtained for contact with SCHOOL MEDICAL PROVIDER and PREVIOUS BEHAVIORAL HEALTH TREATMENT PROVIDER Complete required information about the member s treatment plan THE TREATMENT PLAN WAS DEVELOPED WITH THE MEMBER OR HIS HER GUARDIAN AND HAS MEASURABLE TIME LIMIT GOALS DOES A DOCUMENTED GOAL ORIENTED TREA
31. ndicating that the request requires further review The Results screen provides a summary of information about the request Print the request Click the Print Authorization Result button to print a copy of the Results page Click the Print Authorization Request button to print a copy of all the screens fields completed for the request including the clinical information entered and the Results page Download the request Click the Download Authorization Request button to save a copy of the request either in pdf format or xml Exit the Request for Authorization function Click the Return to Provider Home to exit the Request for Authorization function 35 IT Product Support Reston VA
32. ol d Enter the provider s first and last names in the First Name and Last Name fields Enter the name of the person to contact at the office in the Contact Name field Enter the provider CBHPOO in the Provider ID field Must be capitalized Newly enrolled Providers will be mailed their Provider ID s by COBH Contact Provider Relations at 877 286 2524 to obtain your CBHP Provider ID number if needed Enter the nine digit Federal ID number or Social Security number in the Tax ID field Enter the Provider Group Facility or Clinic Name if needed Enter the provider s primary e mail address in the Primary Email Address field Note The e mail address must be in an abc xyz com format Enter the same e mail address in the Verify Primary Email Address field Enter Secondary Email Address if needed Enter a ten digit phone number without dashes in the Phone Number field 0 Enter a ten digit number without dashes in the Fax Number field Staging Provider Online Services Registration Required fields are denoted by an asterisk J adjacent to the label First Marne Last Hame Contact Hamme Provider ID 7 Tax ID Provider Group Facility or Clinic Name Cif applicable Primary Email Address Verify Primary Email Address Secondary Email Address Phone Number Z agit number without dashes Ext Fax Number 10 aot number without dashes j 6 IT Product Support Reston VA ProviderConnect Basi
33. or the member Demographics Enrollment History COB Additional Information Member eligibility does not guarantee payment Eligibility is as of today s date and is provided by our clients 7 View Member Auths Displays Member specific authorizations 8 Enter an Authorization Initiates the Request for Services process 9 View Clinical Drafts Display member specific Clinical Drafts 10 View Referrals For Residential Group Home Providers Only Work Phone Relationship Gender View Member Auths Enter Auth Request View Clinical Drafts View Referrals 9 IT Product Support Reston VA Features Saving Requests While working with requests for authorizations in ProviderConnect providers have as Drafts the ability to save a request as a draft in the event that they cannot complete it at the time the request was started Saved drafts can be viewed and opened by providers from the View Clinical Drafts screen accessible from the ProviderConnect homepage view Clinical Drafts Ler Recent Inquires Responded to by ValueOptians Enter Bed Tracking DATE RECEIVED SUBJECT Information ke eV Es el y lt zy vin S E JE ae EE Ket t 07 28 10 REFERRAL My Online Profile WHAT DO YOU WANT TO DO TODAY Eligibility and Benefits m Find a Specific Member Enter or Review Authorization Requests m Enter an Authorization Request E Review an Authorization E View Clinical Drafts Saved drafts are available
34. r the same member provider and other matching criteria If the system finds an existing authorization that matches the criteria and the request is determined to be concurrent then the system will Pre populate some information from the last request into fields in the new concurrent request The pre populated fields can be overwritten with new data Require additional information The same screens are completed for initial and concurrent requests however any data that is not expected to be updated for a concurrent request will auto populate from the initial or last request Concurrent When completing concurrent requests for Outpatient Services there are system Outpatient checks that are completed at the beginning of the request specific to this type of Services request The purpose of these checks is to enforce established rules for concurrent Validations and Outpatient services authorizations Checks Concurrent When the level of service is Outpatient Community Based a request will be Check determined as concurrent based on the Concurrent Review Check parameters set up for COBH In general there are three types of checks for determining if a review should be concurrent See below for details on each type of check The specific rules may vary depending on the Level of Care and Type of Care Key Steps The key steps for creating concurrent requests for Outpatient Services include 1 Initiate a Request for Authorization 2 Complete the
35. s using the alphabetized hyperlinks at the top A B C D E L etc AGE MINUTES COMMENTS Achenbach Child Behavior Checklist CECL Behav Rating Scale 4 16 L Adaptive Behavior Assessment System ABAS II Behay Rating Scale 0 89 Adolescent Apperception Cards Proj Thematic 12 19 Adolescent Psychopathology Scale Objective personality test Child adul 6 Alcohol Use Inventory Delete Drinking Styles 16 nhasis Screening Test Reitan Indians Heurn Lannuane Click Save after all tests have been chosen for request Users can enter up to 3 additional psychological neurological tests not included above and choose the time required in the drop down menu NOTE COBH providers can utilize Other Psych Tests fields to indicate the Psych Testing Evaluation 90801 Report Writing Explanation of Results etc The application will automatically calculate the hours requested through the search menu and other psych tests entered by the user Click Submit 34 IT Product Support Reston VA Completing Requests for Psychological Testing continued Key Step 4 Once the Submit button is clicked on the Psychological screen the submission Submit Request screen will display and Confirm Submission Below is information for pended requests Auto Pended Requests Action Once the Submit button is clicked the Results screen will display o Psychological Testing Requests will indicate Pended at the top of the screen with a message i
36. the required fields specific to the level of service 19 Select the Type of Service Mental Health for Psychological Testing services 20 Select the Level of Care Outpatient 21 Select the Type of Care The level of care amp provider type of the service Psych Testing Comm Mtl Hlth Ctr Psych Testing Office etc 22 Attach a document COBH registered services do not require attached documents users can proceed to step 7 23 Click the Next Button A warning message will pop up to confirm if you want to proceed without attaching a document Click the OK button to proceed Staging Requested Services Header All elds marked with an asterisk are required Note Disable pop up blocker funclionality to view all appropriate links Level of Service OUTPATIENT COMMUNITY BASED Provider Provider Last Name Vendor ID Provider Alternate ID 060646665 HARTFORD DISPENSARY CB006009 004175776 Member L Date of Birth MMDDYYYY TEMP000700058 WOODSIN 01151995 Attach a Document Complete the form below to attach a document with this Request The following fields are only required if pou are uploading a document n Document Type Does this Document contain clinical information about the Member Yes O No O bi SELECT UploadFile Ciok to artach a document Attached Document Microsoft Internet Explorer gt WARNING You have not attached document to this Request Please click CANC
37. to the screen to attach document or click OK to proceed with your request without attaching document 14 IT Product Support Reston VA Completing Requests for Outpatient Evaluations continued Key Step3 For Outpatient Evaluation requests the clinical screens for the ORF1 workflow will Complete the display This workflow consists of one clinical screen that must be completed The ORF1 Clinical screen is labeled as Type of Services and minimal data is required to complete the Screens screen Below are the key actions for completing this step Any field with an asterisk indicates that the field is required Enter the Diagnosis Code 1 for Axis I Note An Axis I DIAGNOSIS CODE must be entered to proceed with request a A deferred diagnosis of 799 9 will auto populate to this field and may be modified b The Axis I II field titles Diagnosis Code Description are hyperlinks If the field is empty or partially completed users can click on the underlined field titles to open pop up windows with a list of diagnosis codes or descriptions 2 Enter a Diagnosis Code for Axis Il if needed 3 Click the Submit button B Sta going ProviderConnect Home PAGE 1 of 2 li Requested Services Header Requested Start Date Member Name Provider Name Vendor ID 08 17 2010 WOODSIN MOONEY HARTFORD DISPENSARY THE YCB004514 DE Type of Request Member ID Provider ID Provider Alternate ID NPI for Authorization
38. ton to continue The Requested Service Header will display HARTFORD DLSPENSARY CBHRPUUU4I4 VI Select Service Address Provider ID Last Name vendor ID vendor Last Name First Name vendor First Name ab Service Address Paid To Yendor ID Pay To Address CBHPOO0454 HARTFORD DISPENSAR WOBOOOS 76 HARTFORD DISPENSARY THE 060646665 345 MAIN ST 345 MAIN 5T HARTFORD CT 06106 1824 HARTFORD CT 06106 1824 004175776 CBHPOO00454 HARTFORD DISPENSAR WOBOO439 HARTFORD DISPENSARY 060646665 12 WESTON ST 12 WESTON ST HARTFORD CT 06120 1504 HARTFORD CT 06120 1504 004175776 CEHPOD0454 HARTFORD DISPENSARY WCBOO3251 HARTFORD DISPENSARY 060646665 13 WESTON ST 13 WESTON ST HARTFORD CT 06120 1504 HARTFORD CT 06120 1504 0 CBHPOOD454 HARTFORD DISPENSARY WOBOOG009 HARTFORD DISPENSARY THE Oo0646665 339 BROAD ST 339 BROAD ST MANCHESTER CT 06040 4036 MANCHESTER CT 06040 4036 004175776 13 IT Product Support Reston VA Completing Requests for Outpatient Evaluations continued Key Step 2 The second key step is to complete the initial entry screen of the request where the Complete Initial requested start date of the service is entered and the specific level of care and Entry Request service that is being requested is selected This screen displays for all types of Screen requests However the information entered determines which clinical screens will display and which authorization parameters will be applied to t
39. ut the Member Ves O No O SELECT UploadFile Chok to attach a document Attached Document Microsoft Internet Explorer WARNING You have not attached a document to this Request Please click CANCEL to return to the screen to attach document or click OK to proceed with your request without attaching document 29 IT Product Support Reston VA Completing Concurrent Requests for Registered Services continued 8 Click the Process Continuing Care Concurrent Request to complete the Concurrent Request sig Requested Services Header Requested Start Date ovider Name vendor ID 08 08 2010 TOMPKINS JOUFU WHEELER CLINIC INC CB003370 Type of Request Member ID Provider ID Provider Alternate ID NPI for Authorization CONCURRENT TEMP000700081 CBHP000766 004039368 SELECT M Level of Service Level of Care Type of Care vice Type of Service INPATIENT HLOC Mental Health Group Home Group Home 2 0 There is an existing authorization that bridges this date range Is this a request for continuing care concurrent request or do you wish to enter Discharge information Process Continuing Care Concurrent Request Enter Discharge Information Key Step 3 The Type of Services screen is the first screen that will display after the Initial Entry Complete the screen Clinical Screens ORF2 The same screens are completed for initial and concurrent requests However as noted any data that is not exp
40. uthorization Letters a Enter an Authorization Request t Enter Bed Tracking Information a Review an Authorization e View Clinical Drafts 17 IT Product Support Reston VA Completing Initial Requests for Registered Services continued 2 Review the Disclaimer and click the Next Button 3 Disclaimer Please note that ValueOptions recognizes only fully completed and submitted requests as formal requests for authorizatior recognize or retain data for partially completed requests Upon full completion of the Enter an Authorization Request pri notification that your request has been received by ValueOptions 4 Search for Member Record Member s Medicaid ID and Date of Birth are required Required fields are denoted by an asterisk J adjacent to the label Verify a patient s eligibility and benefits information by entering search criteria below Member ID temp000 700053 Vo spaces or dashes Last Marne First Marne Date of Birth 01151995 MMDDYYYY As of Date 06172010 MMDDYYYY 5 Click the Next button on the Member record to continue Men ber Member ID T E i E l l L IDI i EE Alternate ID Member Hame nar O O O S Ii HOONES Cate of Birth LE E E Da E r Sod dress S00 ENTERPRISE DOF HARTFORD He EF pb Alternate Address Marital Status Home Phone wy ork Phone Relatianship Sender 6 The Select Service screen will display 18 IT Product Support Reston V
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